This was analysed and presented as in Figure 2:
Figure 2. Results analysis model

Students’ results
Questionnaire
Online questionnaires were completed and returned by 6% (36/600) of students. Response rate was comparable between the three year groups, 13, 12 and 11 responders, respectively. The majority of clinics were attended at one hospital trust (61%) and 32% were at two other local hospital trusts, 16% at each. The remaining 7% were at local GP practices.
Most students (n=30) were in their twenties. Four were aged 30 to 40, and two were from >40 age group. There were more female than male respondents (61 vs 33%). Most students in this survey attended medical clinics (80%), 16% attended a surgical and the rest attended other clinics. Students participated in the study attended a mean average 24.77 clinics per year (SD 13.22).
Students were asked about the most preferred teaching style during outpatient clinics. Most respondents preferred to see patients under observation, see table 1:
Table 1. First preference of teaching style selected by students
Teaching style
|
% of students (number of students)
|
See patients under observation
|
55% (n=20)
|
See patients independently
|
22% (n=8)
|
Discuss with teacher in-between patients
|
16% (n=6)
|
Observe
|
5.5% (n=2)
|
Discuss at the end of a clinic
|
0
|
Respondents were asked about the different styles of teaching adopted during clinics they have attended. Observing during clinic, followed by discussing between patients and seeing patients under observation were the most experienced learning styles (Figure 3). Student’s response did not differed between trusts.
Figure 3. Number of students who have experienced different styles of teaching during the clinics they have attended

Most respondents indicated that, time was the main limitation to outpatient teaching, followed by teacher’s interest or attitude toward teaching. Space was the third on the list of limitations (Figure 4).
Figure 4. The number of students selecting each limitation to outpatients teaching

Respondents indicated, on scale of 1-10 (where 10 is very strongly agree), that they feel outpatient teaching has a positive influence on learning, mean value of 7.39 (SD 1.65). The majority (80%) of students, who completed the questionnaire, ‘enjoy’ or ‘very much enjoy’ learning in outpatient clinic in a five points Likert scale (Appendix 1).
In the open question the students were asked; how to improve outpatient teaching. Responses were themed and accompanied by example quotations in table 2 below:
Table 2. Main themes from students’ comments on how to improve outpatient teaching and number of students (N) commented on each theme
Theme
|
N
|
To see patients under observation/ independently:
‘Medical students to see at least one patient independently during clinic’
Teachers attitude to teach:
‘Having an enthusiastic teacher. This is the single biggest factor affecting utility of clinics for me’
Discuss during clinics:
‘Generally good learning can happen when the doctor (teacher) involves the student in some aspects of the consultation…’
Teaching clinics:
‘Having specific teaching clinics which students can sign up for will help the learning process…’
Time and space:
‘ More time and space to be able to do student consultations under observation or independently in a separate room and then report back’
|
12
10
8
6
4
|
Focus Group
The Data from the focus group was analysed via NVivo software and coded into themes. This has revealed three main themes; teaching style during clinics, limitations to outpatient teaching with three subthemes, and how to improve teaching.
Teaching style. Participants reported different styles during clinics and this includes; observing, discussing between patients, active participation, fully or partially, during history taking or examination or both. The style also seemed to differ depending on the type of clinic and the student’s year of study.
…You are either sat in the corner quietly throughout or like a piece of furniture in the room that is listening or you are questioned in between patients very intensively…
Focus group participants preferred a mix of styles depending on clinic type, year of study and confidence of the student. In orthopaedics clinics, for instance, the most preferred style during outpatient teaching is seeing patients under observation. While in medical clinics discussing between patients initially and then seeing patients separately was more desired.
I think personally I prefer having a bit of a mixture of being involved and also having discussion and having time to ask questions or answer questions, a bit of a combination
Limitation to outpatient teaching. The most common limiting factor to outpatient teaching from participants’ point of view was poor communication and preparation before clinics. All six participants motioned this to be an important limitation. This included information given by the university about clinics available, or with individual department and the consultants they are assigned to. This can results in clash between students seeking the same clinic or between students and other disciplines, like nurses, physician associates and junior doctors.
I think one of the limitations is simply on probably availability I would say, on being able to, or knowing what clinics are going on even. Because again, unless you happen to know about things because you know of a certain consultant or the consultant you are assigned to that sort of thing if you have nothing to go on it is a bit more hit and miss.
Teachers’ interest and attitude was also highly featured in participants’ responses. Five students considered teachers’ interest and willingness to involve them during consultation is vital to the success of learning process.
Being willing to get students involved, even to a small extent from asking a few questions during the consultation about the disease area to getting students to do parts of the history or exam, or interpret an investigation.
Another student suggested that wrong technique or rushed examination by the teacher can negatively influence student’s behaviour.
‘We can pick up bad habits by watching the quick examinations’
Time was the third most common limitation featured. This was mentioned by four participants to be one of the limitations to outpatient teaching.
How to improve teaching. Students in this group agree that preparation and prior agreement with consultant is the most important step in order to improve not only students’ attendance but also the learning experience during clinics. This will allow students to prepare before clinics and insure no clashes with other students. There were few other suggestions which are summarised with example quotation in table 3 below:
Table 3. Focus group participants’ suggestions on how to improve outpatient teaching
Information about clinic times and whereabouts:
‘giving forms out when you are on a certain block, these are all the different clinics going on, so that you can organise your own learning’
Understanding medical school structure:
‘Consultants should read a quick A4 document from the medical school that says in 1st year they are doing this, in 2nd year, 3rd year ,4th year this…’
Preparation before clinic:
‘…read up on the subject that I will be doing so I had proper questions to ask and refreshed my knowledge’
Engage students during clinic:
‘while you are doing your notes or dictation say read through that and tell me about the next patient’
Involve other trainees in teaching:
‘Registrars are an unutilised resource and a lot of them are interested in teaching…’
|
Consultants’ results
Questionnaire
Out of 410 consultants, 46 (11.2%) completed the on-line questionnaire. The mean number of years spent at consultant level was 9.35 (SD 6.72). Most consultants (95%) did two to three clinics per week, mean number of 2.59 (SD 1.03). Four percent of consultants do not have any outpatient clinics commitments as part of their role. Consultants had about two students sat with them in clinic, mean number of 1.52 (SD 1.47).
There were similar numbers of male and females respondents (n= 24 vs 21). All respondents were at a consultant level amongst which 6.5% (3/46) were professors or associate professor. Respondents were from a wide range of specialties.
Consultants were asked to choose their usual adopted teaching style during outpatient clinics, more than half (n=26, 57.9%) indicated that they discuss with students between patients. 22% (n=10) chose ‘see patient under-observation’ and 20% (n=9) used a combination of methods or had no students allocated to them. None of the respondents chose the other three styles listed in the questionnaire (Figure 5).
Figure 5. Consultant's teaching style during outpatient clinics

Teachers were then asked about the limitations, they face, to outpatients teaching. Time and space were the most chosen limitations by consultants 40/46 (Figure 6):
Figure 6. Most chosen limitations to outpatient teaching by consultants

Six consultants who completed the questionnaire did not answer the question about their preferred teaching environment. Of those who answered, more than half (57%, 23/40) chose a combination of outpatient and inpatients to be their preferred environment for teaching.
Consultants were asked to indicate how much they enjoy outpatient teaching on a scale where 5 is ‘very much enjoy’, the mean score was 4.1 (SD 1.58). Respondents were then asked for their suggestions on how to improve outpatient teaching. Their answers were themed, in table 4 below, alongside example quotations.
Table 4. Main themes from consultants’ comments on how to improve outpatient teaching and number of consultants (N) commented on each theme
Theme
|
N
|
Time and space:
‘Time for student preparation and briefing before and after consultations/ separate space for students to examine patients’
Teaching clinics:
‘Separation of teaching and service clinics so that those that wish teach and have the skill to do so have the time to give to students.
Advanced notice/planning:
‘Prior warning that students will attend. Better preparation of students by medical school and student self-preparation.
|
18
15
7
|
Quarter of the respondents had specific training in outpatient teaching (12/46). Of those who didn’t have any training, 62% (23/37) would consider having such training.
Interviews
Four consultants volunteered to take part. Only three interviews were analysed as the fourth interview was not recorded due to equipment failure, however, field notes were taken during all interviews. Consultant’s experience at this level was ranging between 5 and 30 years. There was one female and three males. After analysis, four themes were identified; teaching styles, limitations, how to improve outpatient teaching, and their views on teach the teacher courses.
Teaching styles. Teaching style greatly varied between consultants, the type of clinic and the complexity of the patient. In this group of consultants, teaching style practiced mostly is not the preferred style for that consultant, however due to limitations (as outlined below) their teaching style has changed to adapt to circumstances. Consultants seem to employ a mixture of teaching styles depending on multiple variables, like number of patients and or students, complexity of patients and room availability.
Limitations to outpatient teaching. The most common and recurring limitation is time, which was cited by all four consultants in this group, followed by space which was mentioned by three of them. Student interest and lack of preparation has also featured by one of the consultants.
I find it incredibly frustrating when I am getting by week 6 and they still can’t tell me what the common drugs for [a condition] that shows me a lack of interest and a lack of engagement in wanting to make the most of that opportunity
How to improve outpatient teaching. Provide more time and space where students can see patients independently. Preparation and meeting with the consultant beforehand to set goals was vital for a successful learning opportunity. The ideal way to improve teaching process in one consultant interview was to ask for feedback.
Their feedback will be extremely valuable. Before you start teaching there should be a named objective, with the medical students, what we are going to learn.
Teach the teacher courses. Three out of four Consultants in this group did not think teaching courses would be beneficial. One even suggested that unless consultants have interest in teaching, teaching courses will not be helpful.
‘You might teach them how but will they ever even apply it, because they don’t have the interest? Whereas those of us that have the interest probably also have the natural ability to do it as well. So it may or may not make a difference’